Addiction definition in flux

In September, Yale professor of psychiatry Marc Potenza published a letter in the journal “Addictive Behaviors” on how the definition of “addiction” had broadened in the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released this spring. In earlier versions of the DSM, the term “addiction” was linked only to substance-use-related behavior, but in the new manual, the definition has expanded to include non-substance-related behaviors such as gambling. According to Potenza’s letter, researching addictive behaviors not related to substances, including food, the internet, and video games, is critical because it can provide a foundation for improving public health through better approaches to policy, prevention and treatment. The News asked Potenza about the changing use of the term addiction in the DSM, and how the shift will impact policy and our understanding of compulsive use.

Q. How has the definition of addiction changed in the DSM-5?

A. Historically, the term addiction has been absent from the DSM. The category has been described as substance-use related disorders, or something along those lines in DSM-III, DSM-III-R, and DSM-IV. In leading up to DSM-5, there were discussions with DSM-5 research work groups and the DSM-5 committee, specifically the substance use and related disorders committee and the work groups. Basically there were some mixed views. Some people felt that the term addiction was stigmatizing and may lead people not to seek treatment. Other people felt that the term addiction more accurately captured the condition given data that, for example, suggests similarities between substance-use behaviors and non-substance-use behaviors, such as gambling, that may have addictive potential.

Q. Why do you think that the definition of addiction is changing?

A. I’m not sure if the definition is changing. If one goes back to the original use of the word addiction, it was not linked to substance-use behaviors. It’s derived from a Latin word, “addicere,” meaning “bound to,” or “enslaved by.” But going back several hundred years, it became linked to excessive patterns of alcohol use, and then, more recently linked to excessive patterns of drug use, such that by the time of DSM-III-R in the 1980’s, the committee felt that addiction was equivalent to compulsive drug use. I think that over the past 10, 15 years, there’s been a reconsideration of what are the core elements of addiction. Some people have proposed that some elements such as compulsive engagement in a behavior, continued engagement in a behavior despite adverse consequences, and a repetitive urge or craving state prior to initiation of the behavior [are] all core elements of addiction. If one considers those as core elements, then the addictions may not be limited to substance-use disorders.

Q. Given this broad definition of addiction, do you think we all have problems with addiction on some level, or should we think of addiction as a clinical disorder that only certain people have?

A. I think that many people engage in behaviors that may have addictive potential without developing problems. So, for example, gambling [and] alcohol use are two good examples, in that most people gamble, most people drink alcohol, but most people don’t develop problems with the behaviors in a manner that interferes significantly with their life functioning. However, for the group of people who encounter such problems, they can be substantial, life changing, and really significant.

Q. Do you think that the way that young people today use Facebook could classify as an addiction? Many teenagers I know can’t go a day without logging on at least once.

A. I think it’s a fair question to ask, and I suspect that it will be debated much the way that whether gambling is an addiction or not has been debated. In the provisional diagnoses section, there’s something called “Internet Gaming Disorder,” which I think is the closest thing, presently, to what you’re asking. If there are groups of people who engage in Facebook-related behaviors to the extent that they don’t do their homework, get failing grades, don’t keep up with other major life activities, become isolative, etcetera, then the way in which they’re using the internet impacts their life, and should be considered from a health perspective. I think given the substantial changes in social networking and the use of the computer over the past generation, that this is something that people should keep an eye on and investigate further.

Q. How do you think that the way the term “addiction” is defined can influence both health professionals and policy-makers?

A. That’s a good question. I think that it could influence people in many different ways. A few years back, we published an article, thinking about whether food may be addictive, particularly in the setting of the current obesity epidemic. From a policy perspective, if one thinks about the approaches that one has used that have been effective in curbing addictive behaviors like smoking, then one might think that some of these might be adopted for food. This is still very much debated in the field. So I think it’s an area that deserves interest, has significant health implications [and] policy implications. I think that it will continue to evolve.